Community Centers Take Up Lung Screening Torch

Posted by Samantha Powell on April 29th, 2014 |

News Headline: Community Centers Take Up Lung Screening Torch
Date: 4/29/14
Outlet Full Name: Med Page Today
Author: Crystal Phend

Lung cancer screening programs at community hospitals have seen a dramatic rise over the past year, which may be key to uptake among at-risk individuals, experts said.

The number of centers identified by the Lung Cancer Alliance as screening centers of excellence, determined by meeting certain criteria for performance and a commitment to send data to a registry, more than doubled over the past year, with an increasing proportion of community centers.

“Absolutely it’s a good thing,” said Amy Copeland, MPH, director of medical outreach at the organization. “Getting community cancer centers involved in the process, not only can be done in a high quality responsible way, but it ensures access to people all over the country that may benefit from this service.”

The less patients have to travel to get screened, the more likely they may be to do so, she noted.

“If we want to make it easy for them to get this care, it has to happen in their community and they have to have the resources within their community to treat the cancer in an appropriate way,” she told MedPage Today.

That preference for care close to home has been shown in treatment.

In one study of Medicare-linked data, the likelihood of attending a National Cancer Institute-designated cancer center dropped by a significant 11% for every 10 minutes of additional travel time from home.

For screening in particular, “it’s also a matter of where are patients comfortable getting their care,” noted Elyse Gellerman, MHS, regional vice president of oncology services at Denver’s HealthONE community hospital system.

“If we look at mammography or colonoscopy these are, by and large, provided in the community setting,” she told MedPage Today in an interview monitored by media relations there.

Driving Growth

The pivotal data pushing acceptance of lung cancer screening in the medical community and in preventive services guidelines — a 20% lung cancer mortality reduction with annual screening of high-risk smokers and former smokers in the National Lung Screening Trial (NLST) — mainly came from major academic medical centers.

A survey of the 21 leading academic centers identified by US News and World Report showed that 15 already had an active screening program by March 2013 and the other four responders had one planned, suggesting little additional room for growth in that category of centers.

Community centers appear to be the driver of the swelling ranks of those offering CT-based screening for lung cancer.

The Lung Cancer Alliance database of screening centers of excellence, determined by meeting certain criteria for performance and a commitment to send data to a registry, shows that growth.

As of April 2013, roughly 85 centers were on that list, a third of which were academic hospitals. By December, that number had climbed to 140.

Now in April 2014, the list of screening centers maintained by the Lung Cancer Alliance is up to 172.

The proportion of university hospitals has fallen to about 20%, suggesting that the increase has disproportionately been in community centers, Copeland noted.

“It does appear to be moving in that direction,” she said.

Most of the growth appears to be in anticipation that Medicare and other payers will soon jump in step with the U.S. Preventive Services Task Force’s recommendation for annual low-dose CT screening for high-risk individuals, ages 55 through 79, who have a 30 pack-year history of smoking or who have quit in the past 15 years.

“Programs, hospitals and practices, certainly want to be ready for broad-scale screening,” noted Phillip Boiselle, MD, of Beth Israel Deaconess Medical Center in Boston.

That hasn’t happened yet, he noted, pointing to the disconnect between the increasing availability of programs and the relatively small numbers of patients getting screened when his group surveyed academic medical centers.

“Coverage is a major barrier at present for patients,” he told MedPage Today.

A few insurers already cover CT screening for lung cancer, but the Centers for Medicare and Medicaid may move things along if it decides to reimburse the procedure as well.

The agency’s advisory committee meets Wednesday to deliberate on a national coverage determination.

If (or more likely when) Medicare starts to cover lung CT screening, the sheer number of patients eligible for screening under the USPSTF recommendation — an estimated 7 to 9 million — is another reason community centers are needed on board, Boiselle noted.

Which Criteria?

However, many community centers aren’t sticking to just that population.

About half of the centers the Lung Cancer Alliance works with follow the criteria that most closely match up to the federal task force guidance, the NLST criteria.

HealthONE opted for those criteria for the lung cancer screening program at its six hospitals started up around September 2013, after a year and a half of work to add it atop the existing infrastructure of a suspicious nodule program.

While lots of phone calls come in, dedicated patient navigators narrow down only those who fit the criteria and want to pursue screening after getting a full explanation, Gellerman noted.

A large proportion of other centers follow the broader National Comprehensive Cancer Network criteria, which start screening at 50 instead of 55 and at a smoking history of 20 instead of 30 pack-years for those with additional risk factors, such as occupational exposure to carcinogens like asbestos.

A number of the rest are participating in the International Early Lung Cancer Action Project(I-ELCAP) and set whatever protocols make sense for them, including some that screen below 50 age, Copeland explained.

One such center is El Camino Hospital in Los Gatos, Calif., where the screening program incorporates a genetic test, family history, and social factors to identify high-risk individuals ages 50 or older.

Those modified criteria are an attempt to narrow the screening population so “we’re not exposing 9 million people to CT scans,” said Elwyn Cabebe, MD, who is leading the experiment (dubbed the REACT trial) at El Camino Hospital.

However it’s done, “in order to see a meaningful impact, screening really needs to be deployed in all communities,” he told MedPage Today.

There are questions, though, about how the diverse criteria and variety of protocols for managing suspicious nodules will impact patient outcomes and the risk-benefit balance, noted Douglas Arenberg, MD, director of lung screening at the University of Michigan in Ann Arbor.

“Far more important than … where it’s being done is if it’s being done with the same quality that the initial NLST was carried out with,” he told MedPage Today. “And equally important after that is what you do with the results.”

Even in the NLST, nearly all of the 24% of patients with a positive CT scan went on to diagnostic evaluation, although 96% turned out to be false positives, leading to some unnecessary biopsies and other procedures.

“It is possible that community facilities will be less prepared to undertake screening programs and the medical care that must be associated with them,” those researchers had warned in the New England Journal of Medicine publication.

“For example, one of the most important factors determining the success of screening will be the mortality associated with surgical resection, which was much lower in the NLST than has been reported previously in the general U.S. population (1% vs. 4%).”

Guidelines on the “nuts and bolts” are underway from the American College of Radiology and Society of Thoracic Radiology to help ensure uniformity and a high level of quality, regardless of where patients get screened, Boiselle noted.

For now, Boiselle pointed clinicians to a bundle of existing documents on the Journal of Thoracic Imaging website, which he edits.

“This is such an historic opportunity to save lives from lung cancer, but [we need to] make sure it’s offered in a way that provides uniform access to high quality care and the best chance of achieving results similar to the NLST,” he told MedPage Today.

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